Inspection·March 4, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, physician interview and review of facility policy, the facility failed to notify the physician timely of abnormal laboratory (lab) results. This affected one (#19) of three residents reviewed for notification of change. The facility census was 68. Findings include: Review of Resident #19's medical record revealed an admission date of 11/25/14. Diagnoses included dementia, anxiety, psychotic disorder, hypertension (HTN), unspecified symbolic dysfunctions, hyperosmolality and hypernatremia, chronic kidney disease (CKD) stage 3B, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/20/25, revealed a Brief Interview of Mental Status (BIMS) score was unable to be determined due to Resident #19's cognition. Further review of the medical record revealed Resident #19 had routine labs drawn on 01/15/25, including a complete metabolic panel (CMP) and a complete blood count with differential (CBC w/diff). The labs were resulted and reported to the facility on [DATE]. Additional review of the lab report revealed Resident #19 had an elevated sodium level of 156 milliequivalents per liter (mEq/L), with the normal reference range being 136-145 mEq/L. An illegible, handwritten marking was observed on the facility copy of the lab results. Further review of Resident #19's medical record revealed no evidence the physician was notified of the abnormal lab values on 01/15/25. Interview on 03/04/25 at 11:25 A.M. with Medical Director (MD) #185 revealed he was unsure of when he was notified of Resident #19's lab results, stating it had been over one month ago. Interview on 03/04/25 at 2:32 P.M. with the Director of Nursing (DON) revealed Resident #19's labs were collected and resulted on 01/15/25. The DON verified the facility had no evidence MD #185 was notified of the abnormal lab results on 01/15/25. The DON stated the illegible marking on the lab report was MD #185's signature and a date of 01/16/25, when she stated he reviewed the results during rounds at the facility. Review of the facility policy titled, Change in a Resident's Condition or Status, revised November 2015, revealed the nurse supervisor/charge nurse would notify the resident's attending physician or on-call physician when there was a need to alter the resident's medical treatment significantly. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 366041 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addison Heights Health and Rehabilitation Center 3600 Butz Rd Maumee, OH 43537 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)